SlideShare ist ein Scribd-Unternehmen logo
1 von 69
Downloaden Sie, um offline zu lesen
TRACHEOSTOMY 
--- Prashiddha Dhakal 
MBBS,KUSMS
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
Tracheostomy
Functions of Tracheostomy 
1. Alternative pathway for breathing 
2. Improves alveolar ventilation In cases of respiratory insufficiency : 
(a) Decreasing the dead space by 30-50% (normal dead space is 150 ml). 
(b) Reducing the resistance to airflow. 
3. Protects the airways By using cuffed tube, tracheobronchial tree is protected against 
aspiration of: 
(a) Pharyngeal secretions, as in case of bulbar paralysis or coma. 
(b) Blood, as in haemorrhage from pharynx, larynx or maxillofacial injuries. With 
tracheostomy, pharynx and larynx can also be packed to control bleeding. 
4. Permits removal of tracheobronchial secretions 
When patient is unable to cough as in coma, head injuries, respiratory paralysis; or 
when cough is painful, as in chest injuries or upper abdominal operations, the 
tracheobronchial airway can be kept clean of secretions by repeated suction through the 
tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not 
only traumatic but requires expertise. 
5. Intermittent positive pressure respiration (IPPR) 
If IPPR is required beyond 72 hours, tracheostomy is superior to intubation. 
6. To administer anaesthesia 
laryngopharyngeal growths or trismus.
Indications of Tracheostomy 
There are three main indications 
A. Respiratory obstruction. 
B. Retained secretions. 
C. Respiratory insufficiency.
A. Respiratory obstruction 
1. Infections 
Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig's angina, 
peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess 
2. Trauma 
External injury of larynx and trachea ,Trauma due to endoscopies, especially in 
infants and children,Fractures of mandible or maxillofacial injuries 
3. Neoplasms 
Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and 
thyroid 
4. Foreign body larynx 
5. Oedema larynx 
due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), 
radiation 
6. Bilateral abductor paralysis 
7. Congenital anomalies 
– Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia
B. Retained secretions 
1. Inability to cough 
– Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic 
overdose 
– Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre 
syndrome, myasthenia gravis 
– Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning 
2. Painful cough 
– Chest injuries, multiple rib fractures, pneumonia 
3. Aspiration of pharyngeal secretions 
– Bulbar polio, polyneuritis, bilateral laryngeal paralysis
C. Respiratory insufficiency 
• Chronic lung conditions, viz. emphysema, chronic bronchitis, 
bronchiectasis, atelectasis.
Types of Tracheostomy 
• Emergency tracheostomy 
• Elective or tranquil tracheostomy 
• Permanent tracheostomy 
• Percutaneous dilatational tracheostomy 
• Mini tracheostomy (cricothyroidotomy)
1. Emergency tracheostomy 
• It is employed when airway obstruction is complete 
or almost complete and 
• There is an urgent need to establish the airway. 
• Intubation or laryngotomy are either not possible or 
feasible in such cases.
2. Elective tracheostomy 
(syn. tranquil, orderly or routine tracheostomy) 
• This is a planned, unhurried procedure. Almost all operative 
surgical facilities are available, endotracheal tube can be 
put and local or general anaesthesia can be given. 
• It is of two types: 
(a) Therapeutic: to relieve respiratory obstruction, remove 
tracheobronchial secretions or give assisted ventilation. 
(b) Prophylactic: to guard against anticipated respiratory 
obstruction or aspiration of blood or pharyngeal secretions 
such as in extensive surgery of tongue, floor of mouth, 
mandibular resection or laryngofissure.
3. Permanent tracheostomy 
• Required for case of bilateral abductor 
paralysis or laryngeal stenosis.
BASED ON LEVEL 
TRACHEOSTOMY 
HIGH 
MID 
LOW 
above the level of thyroid isthmus 
perichondritis of the cricoid cartilage 
and subglottic stenosis and is always 
avoided. 
Only indication - carcinoma of larynx 
because in such cases, total larynx 
anyway would ultimately be removed and 
a fresh tracheostome made in a clean 
area lower down 
(THYROID isthmus lies against II, III and IV 
tracheal rings). 
preferred one 
Through the II or III rings and would entail 
division of the thyroid isthmus or its retraction 
upwards or downwards to expose this part of 
trachea. 
below the level of isthmus. 
Trachea is deep at this level and close to several 
large vessels; also there are difficulties with 
tracheostomy tube which impinges on 
suprasternal notch.
Technique 
• Whenever possible, endotracheal intubation 
should be done before tracheostomy. This is 
specially important in infants and children. 
• Position 
Supine with a pillow under the shoulders so 
that neck is extended.
Tracheostomy
Anaesthesia 
2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line
Steps Of Operation 
1. A vertical incision in the 
midline of neck, extending 
from cricoid cartilage to just 
above the sternal notch. 
This is the most favoured 
incision and can be used in 
emergency and elective 
procedures. It gives rapid 
access with minimum of 
bleeding and tissue 
dissection.
A transverse incision, 5 cm long, made 2 
fingers' breadth above the sternal notch can 
be used in elective procedures. It has the 
advantage of a cosmetically better scar .
2. After incision, tissues are dissected in the 
midline. Dilated veins are either displaced or 
ligated.
3. Strap muscles are separated in the midline and 
retracted laterally. 
4. Thyroid isthmus is displaced upwards or divided 
between the clamps, and suture-ligated.
5. Trachea is fixed with a hook and opened with 
a vertical incision in the region of 3rd and 4th 
or 3rd and 2nd rings. 
This is then converted into a circular opening. 
The first tracheal ring is never divided as 
perichondritis of cricoid cartilage with 
stenosis can result
Confirmation of trachea 
• 5 ml syringe containing 4 % Lignocaine taken, its needle 
inserted into trachea & aspirated. Air bubbles confirm 
presence of needle in trachea. 
• 2 ml of solution injected into trachea & needle 
removed quickly to avoid breaking of needle during 
violent cough movements.
6. Tracheostomy tube of appropriate size is inserted and 
secured by tapes 
Lubricated tracheostomy tube inserted into trachea 
Confirm presence of tube in trachea with help of ambu 
bag & auscultation
Jackson’s metallic tube
Jackson’s metallic tube 
• Made of German silver (alloy of Ag + Cu + P) 
• Has obturator (pilot), inner tube & outer tube 
• Inner tube is longer than outer tube for its removal & 
cleaning. Outer tube maintains patency. Pilot is inserted 
into outer tube for smooth & non-traumatic insertion of 
tube 
• Lock prevents expulsion of tube during cough
Fuller’s bivalve metallic tube 
I 
O
Fuller’s metallic tube 
• Outer tube bi-valved. The 2 blades when pressed together, 
help in smooth entry of tube. 
• Inner tube is longer & has a vent for phonation 
• Pt phonates by closing main tube opening 
• Vent also helps in decannulation of tube
Portex cuffed tube
Portex cuffed tube 
• Made of siliconized Poly Vinyl Chloride. It is thermolabile 
& prevents crusting. 
• Low pressure high volume cuff maintains an air-tight 
seal required for: 
 Prevention of aspiration of secretions 
 Positive pressure ventilation
Cuffed fenestrated tube
Portex uncuffed tube 
For tracheostomy patient receiving radiation
TYPES OF TRACHEOSTOMY 
TUBES 
• Plastic or metal 
• Cuffed or uncuffed 
• Fenestrated or unfenestrated 
• Double canula or single canula
Tracheostomy
7. Skin incision should not be sutured or packed tightly as it may 
lead to development of subcutaneous emphysema. 
8. Gauze dressing is placed between the skin and flange of the 
tube around the stoma
9.Tapes of tracheostomy tube tied around the neck 
keeping a space for 1 finger. Neck kept flexed. 
Skin incision closed loosely to avoid surgical emphysema.
Insertion of medicated gauze 
Betadine soaked gauze or Sofratulle put around the 
tracheostomy opening.
Paediatric Tracheostomy 
-Soft and compressible trachea ,so difficult to 
identify and may get displaced & injure recurrent 
laryngeal nerve 
-Preferably in general anaesthesia 
-Don’t extend neck too much as pleura,innominate 
vessels,thymus may get injured 
-Post operative x-ray of the neck to know position 
of the tube 
-Use of soft silastic and portex tube
Post Operative Care 
1.Constant Supervision 
• For bleeding, displacement, blocking of tubes, removing 
secretions 
• Patient is given a bell or paper pad to communicate 
• Pt given 100 % oxygen. Deflate the tube cuff.
2.Suction 
• Suction catheter with negative suction pressure (10 -15 
mmHg) used. 
• Catheter diameter should be < 1/3rd of internal diameter of 
tracheostomy tube 
• Catheter length introduced just enough to go beyond inner 
tube (10 cm)
Tracheostomy
3.Tracheostomy tube care 
• Inner tube is removed & cleaned when blocked 
• Outer tube never removed before 72 hrs to allow formation of 
tracheo-cutaneous tract 
• Cuff of Portex tube deflated for 10 minutes every 2 hours to 
prevent pressure necrosis & dilatation of trachea
Cleaning of inner tube
4. Others 
• Chest auscultated for confirmation of adequate suctioning. Re-inflate 
cuff to a pressure of 25 mmHg. Patient oxygenated again. 
• Tracheostomy wound dressing done BID 
• Steam inhalation TID. Moist gauze piece placed over tracheostomy 
tube opening. Regular chest physiotherapy, expectorants & 
mucolytics given.
5.Prevention of crusting and tracheitis 
-Proper humidification using 
humidifier,nebulizer or keeping boiling kettle in 
room. 
-Using a few drops of ringer lactate or normal 
saline or hypotonic saline 
-Every 2-3 hrs
Decannulation 
• Adult: plug or seal tube opening & if tolerated for 24 hrs, remove tube. 
• Child: Sequentially reduce size of tube. After tube removal  close 
wound. Healing occurs within 1 week. Secondary closure after 
freshening the wound margin is required rarely. 
• Infant or a young child 
-Decannulate in operation theatre 
-Equipment for re-intubation should ne available like good headlight, 
laryngoscope, proper sized endotracheal tubes and a tracheostomy tray 
-After decannulation observe for respiratory distress,t achycardia, colour. 
-Oximetry is useful
Tracheostomy
Decannulation difficulty 
Organic causes 
• Persistence of cause requiring 
tracheostomy 
• Obstructing tracheal granulations 
• Tracheal oedema 
• Subglottic stenosis 
• Collapse of tracheal wall 
(tracheomalacia) 
Non-organic causes: 
• Emotional dependence in children 
• Inability to tolerate upper airway 
resistance 
• In-coordination of laryngeal opening 
reflex 
• Long-standing tube leads to impaired 
laryngeal development
Complications of tracheostomy 
1. Immediate Complications (During 
tracheostomy) 
2. Intermediate Complications (Few hours or 
days later) 
3. Late Complications (Due to prolonged use of 
tube for weeks-months)
Immediate complications 
• Haemorrhage 
• Aspiration of blood 
• Injury to recurrent laryngeal 
nerve 
• Injury to apical pleura 
(Pneumothorax) 
• Injury to oesophagus (May 
cause tracheoesophageal 
fistula) 
• Apnoea (Due to Carbondioxide 
wash out)
Intermediate Complications 
• Haemorrhage 
• Displacement of tube (Due to use of improper 
size tube) 
• Blocking of tube (Due to excessive crusting/poor 
humidification) 
• Subcutaneous emphysema 
• Tracheitis/Tracheobronchitis with crusting in 
trachea 
• Pulmonary infections (Due to compromised 
airway defense mechanism) 
• Wound infection & granulation
Late Complications 
• Haemorrhage (Due to erosion of major vessels esp 
innominate/bracheocephalic art) 
• Laryngeal stenosis (Due to perichondritis of cricoid 
cartilage) 
• Tracheal stenosis (Due to tracheal ulceration & 
infection) 
• Tracheoesophageal fistula (Due to erosion of 
trachea by tip of the tube) 
• Persistent tracheocutaneous fistula 
• Keloid/Unsighty scar at tracheostomy site 
• Difficult decannulation
Tracheostomy
Procedure for immediate airway 
management 
1. Jaw thrust 
• Lifting the jaw forward & extensing the neck 
• Improves airway by displacing the soft tissues 
• Avoided in spinal injuries
2. Oropharyngeal airway 
• Displaces the tongue anteriorly & relieves soft 
tissue obstruction 
• Face mask can also be kept
3. Nasopharyngeal airway (Trumpet) 
• Inserted transnasally into posterior 
hypopharynx 
• Releives soft tissue obstruction caused by 
tongue & pharynx
4. Laryngeal mask airway 
• It is a device with a tube & a triangular distal 
end which fits over the laryngeal inlet 
• Oxygen can be delivered directly into the 
trachea
5. Transtracheal jet ventillation 
• An IV cathether with a syringe 
is inserted into the 
cricothyroid membrane & 
directed caudally. 
• Then the needle is withdrawn 
leaving the catheter in 
position & jet ventillation is 
started
Tracheostomy
6. Endotracheal intubation 
• Larynx is visualized with a laryngoscope & 
endotracheal tube is inserted 
• Helps to avoid a hurried tracheostomy in 
which complications are likely 
• After intubation, an orderly tracheostomy can 
be performed.
7. Cricothyrotomy/Laryngotomy/Mini tracheostomy 
• Opening of airway through 
cricothyroid membrane 
• Done only to buy time to 
allow patient to be carried 
to OT 
• Complications– 
Perichondritis,Laryngeal 
stenosis, Sub glottic edema
Percutaneous Dilational Tracheostomy 
•A minimally invasive alternative to conventional 
tracheostomy. 
•Advantages: 
No need of OT, thus is cost effective. 
Forms a stoma between tracheal rings, resulting in 
reduced blood loss as there is usually no disruption of 
blood vessels. 
•Avoided in patients who are obese, have neck mass, 
difficult to intubate, difficult to extend neck, larynx & 
trachea aren’t easily palpable
• Steps: 
1. Neck is extended & incision is given 2cm 
below the lower border of cricoid 
2. Trachea is exposed & thyroid isthmus is 
pushed down 
3. Bronchoscope is inserted to monitor the 
passage of needle,guide wire & dilator which 
are passed into trachea between 2nd & 3rd 
tracheal ring. 
4. After dilatation tracheostomy tube is 
inserted.
Tracheostomy
Tracheostomy
Tracheostomy
Tracheostomy
Tracheostomy
Tracheostomy
Tracheostomy

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Bronchoscopy ppt
Bronchoscopy pptBronchoscopy ppt
Bronchoscopy ppt
 
Tracheostomy ent indications procedure complications ppt
Tracheostomy ent indications procedure complications pptTracheostomy ent indications procedure complications ppt
Tracheostomy ent indications procedure complications ppt
 
ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical Discussion
ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical DiscussionENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical Discussion
ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical Discussion
 
Cvp line
Cvp lineCvp line
Cvp line
 
Endotracheal intubation
Endotracheal intubationEndotracheal intubation
Endotracheal intubation
 
Tracheostomy ( for medical students )
Tracheostomy ( for medical students )Tracheostomy ( for medical students )
Tracheostomy ( for medical students )
 
Endotracheal intubation
Endotracheal intubationEndotracheal intubation
Endotracheal intubation
 
Tracheostomy care
Tracheostomy careTracheostomy care
Tracheostomy care
 
BRONCHOSCOPY
BRONCHOSCOPYBRONCHOSCOPY
BRONCHOSCOPY
 
Tracheostomy ppt
Tracheostomy pptTracheostomy ppt
Tracheostomy ppt
 
Tracheostomy care
Tracheostomy careTracheostomy care
Tracheostomy care
 
Tracheostomy class
Tracheostomy classTracheostomy class
Tracheostomy class
 
Central venous pressure
Central venous pressureCentral venous pressure
Central venous pressure
 
Tonsillectomy
 Tonsillectomy Tonsillectomy
Tonsillectomy
 
Cvp
CvpCvp
Cvp
 
Thoracentesis
Thoracentesis Thoracentesis
Thoracentesis
 
Tracheostomy -INDICATIONS,CONTRAINDICATIONS,PROCEDURE,COMPLICATIONS
Tracheostomy -INDICATIONS,CONTRAINDICATIONS,PROCEDURE,COMPLICATIONSTracheostomy -INDICATIONS,CONTRAINDICATIONS,PROCEDURE,COMPLICATIONS
Tracheostomy -INDICATIONS,CONTRAINDICATIONS,PROCEDURE,COMPLICATIONS
 
Intercostal drainage tube insertion
Intercostal drainage tube insertionIntercostal drainage tube insertion
Intercostal drainage tube insertion
 
CVP Monitoring_Dr. Subrata Kumar_BSMMU_2014
CVP Monitoring_Dr. Subrata Kumar_BSMMU_2014CVP Monitoring_Dr. Subrata Kumar_BSMMU_2014
CVP Monitoring_Dr. Subrata Kumar_BSMMU_2014
 
Tonsillectomy
TonsillectomyTonsillectomy
Tonsillectomy
 

Ähnlich wie Tracheostomy

Ähnlich wie Tracheostomy (20)

Tracheostomy
TracheostomyTracheostomy
Tracheostomy
 
Tracheostomy &amp; tracheal surgeries
Tracheostomy &amp; tracheal surgeriesTracheostomy &amp; tracheal surgeries
Tracheostomy &amp; tracheal surgeries
 
TRACHEOSTOMY
TRACHEOSTOMYTRACHEOSTOMY
TRACHEOSTOMY
 
8-Intubation and tfffffffracheostomy.pdf
8-Intubation and tfffffffracheostomy.pdf8-Intubation and tfffffffracheostomy.pdf
8-Intubation and tfffffffracheostomy.pdf
 
nose and ear pathophysiology,biochemistry,immunology
nose and ear pathophysiology,biochemistry,immunologynose and ear pathophysiology,biochemistry,immunology
nose and ear pathophysiology,biochemistry,immunology
 
Tracheostomy complications pediatric by Aditya Rana mbbs
Tracheostomy complications pediatric by Aditya Rana mbbs Tracheostomy complications pediatric by Aditya Rana mbbs
Tracheostomy complications pediatric by Aditya Rana mbbs
 
Seminar on Tracheostomy, types and its Complications.
Seminar on Tracheostomy, types and its Complications.Seminar on Tracheostomy, types and its Complications.
Seminar on Tracheostomy, types and its Complications.
 
Tracheostomy
TracheostomyTracheostomy
Tracheostomy
 
TRACHEOSTOMY SEMINAR.pptx
TRACHEOSTOMY SEMINAR.pptxTRACHEOSTOMY SEMINAR.pptx
TRACHEOSTOMY SEMINAR.pptx
 
Tracheostomy
TracheostomyTracheostomy
Tracheostomy
 
tracheostomy
 tracheostomy tracheostomy
tracheostomy
 
Surgical airway procedures
Surgical airway proceduresSurgical airway procedures
Surgical airway procedures
 
Surgial airways
Surgial airwaysSurgial airways
Surgial airways
 
Tracheostomy
TracheostomyTracheostomy
Tracheostomy
 
Tracheostomy (sbo 2)
Tracheostomy (sbo 2)Tracheostomy (sbo 2)
Tracheostomy (sbo 2)
 
Tracheostomy tubes by Dr.Ashwin Menon
Tracheostomy tubes by Dr.Ashwin MenonTracheostomy tubes by Dr.Ashwin Menon
Tracheostomy tubes by Dr.Ashwin Menon
 
AIRWAY MANAGEMENT-INTUBATION (2).ppt
AIRWAY MANAGEMENT-INTUBATION (2).pptAIRWAY MANAGEMENT-INTUBATION (2).ppt
AIRWAY MANAGEMENT-INTUBATION (2).ppt
 
Tracheostomy
TracheostomyTracheostomy
Tracheostomy
 
Trachy
TrachyTrachy
Trachy
 
Microlaryngeal surgery
Microlaryngeal surgeryMicrolaryngeal surgery
Microlaryngeal surgery
 

Mehr von Prashiddha Dhakal

Mehr von Prashiddha Dhakal (6)

Safe motherhood
Safe motherhood Safe motherhood
Safe motherhood
 
Vertigo
VertigoVertigo
Vertigo
 
Complications of 3 rd stage of labour
Complications of 3 rd stage of labourComplications of 3 rd stage of labour
Complications of 3 rd stage of labour
 
Serology in hepatitis b
Serology in hepatitis bSerology in hepatitis b
Serology in hepatitis b
 
Egyptian medicine
Egyptian medicineEgyptian medicine
Egyptian medicine
 
Anti anginal drugs
Anti  anginal drugsAnti  anginal drugs
Anti anginal drugs
 

Kürzlich hochgeladen

Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 

Kürzlich hochgeladen (20)

American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 

Tracheostomy

  • 1. TRACHEOSTOMY --- Prashiddha Dhakal MBBS,KUSMS
  • 2. 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
  • 4. Functions of Tracheostomy 1. Alternative pathway for breathing 2. Improves alveolar ventilation In cases of respiratory insufficiency : (a) Decreasing the dead space by 30-50% (normal dead space is 150 ml). (b) Reducing the resistance to airflow. 3. Protects the airways By using cuffed tube, tracheobronchial tree is protected against aspiration of: (a) Pharyngeal secretions, as in case of bulbar paralysis or coma. (b) Blood, as in haemorrhage from pharynx, larynx or maxillofacial injuries. With tracheostomy, pharynx and larynx can also be packed to control bleeding. 4. Permits removal of tracheobronchial secretions When patient is unable to cough as in coma, head injuries, respiratory paralysis; or when cough is painful, as in chest injuries or upper abdominal operations, the tracheobronchial airway can be kept clean of secretions by repeated suction through the tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not only traumatic but requires expertise. 5. Intermittent positive pressure respiration (IPPR) If IPPR is required beyond 72 hours, tracheostomy is superior to intubation. 6. To administer anaesthesia laryngopharyngeal growths or trismus.
  • 5. Indications of Tracheostomy There are three main indications A. Respiratory obstruction. B. Retained secretions. C. Respiratory insufficiency.
  • 6. A. Respiratory obstruction 1. Infections Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig's angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess 2. Trauma External injury of larynx and trachea ,Trauma due to endoscopies, especially in infants and children,Fractures of mandible or maxillofacial injuries 3. Neoplasms Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid 4. Foreign body larynx 5. Oedema larynx due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation 6. Bilateral abductor paralysis 7. Congenital anomalies – Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia
  • 7. B. Retained secretions 1. Inability to cough – Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose – Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre syndrome, myasthenia gravis – Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning 2. Painful cough – Chest injuries, multiple rib fractures, pneumonia 3. Aspiration of pharyngeal secretions – Bulbar polio, polyneuritis, bilateral laryngeal paralysis
  • 8. C. Respiratory insufficiency • Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis, atelectasis.
  • 9. Types of Tracheostomy • Emergency tracheostomy • Elective or tranquil tracheostomy • Permanent tracheostomy • Percutaneous dilatational tracheostomy • Mini tracheostomy (cricothyroidotomy)
  • 10. 1. Emergency tracheostomy • It is employed when airway obstruction is complete or almost complete and • There is an urgent need to establish the airway. • Intubation or laryngotomy are either not possible or feasible in such cases.
  • 11. 2. Elective tracheostomy (syn. tranquil, orderly or routine tracheostomy) • This is a planned, unhurried procedure. Almost all operative surgical facilities are available, endotracheal tube can be put and local or general anaesthesia can be given. • It is of two types: (a) Therapeutic: to relieve respiratory obstruction, remove tracheobronchial secretions or give assisted ventilation. (b) Prophylactic: to guard against anticipated respiratory obstruction or aspiration of blood or pharyngeal secretions such as in extensive surgery of tongue, floor of mouth, mandibular resection or laryngofissure.
  • 12. 3. Permanent tracheostomy • Required for case of bilateral abductor paralysis or laryngeal stenosis.
  • 13. BASED ON LEVEL TRACHEOSTOMY HIGH MID LOW above the level of thyroid isthmus perichondritis of the cricoid cartilage and subglottic stenosis and is always avoided. Only indication - carcinoma of larynx because in such cases, total larynx anyway would ultimately be removed and a fresh tracheostome made in a clean area lower down (THYROID isthmus lies against II, III and IV tracheal rings). preferred one Through the II or III rings and would entail division of the thyroid isthmus or its retraction upwards or downwards to expose this part of trachea. below the level of isthmus. Trachea is deep at this level and close to several large vessels; also there are difficulties with tracheostomy tube which impinges on suprasternal notch.
  • 14. Technique • Whenever possible, endotracheal intubation should be done before tracheostomy. This is specially important in infants and children. • Position Supine with a pillow under the shoulders so that neck is extended.
  • 16. Anaesthesia 2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line
  • 17. Steps Of Operation 1. A vertical incision in the midline of neck, extending from cricoid cartilage to just above the sternal notch. This is the most favoured incision and can be used in emergency and elective procedures. It gives rapid access with minimum of bleeding and tissue dissection.
  • 18. A transverse incision, 5 cm long, made 2 fingers' breadth above the sternal notch can be used in elective procedures. It has the advantage of a cosmetically better scar .
  • 19. 2. After incision, tissues are dissected in the midline. Dilated veins are either displaced or ligated.
  • 20. 3. Strap muscles are separated in the midline and retracted laterally. 4. Thyroid isthmus is displaced upwards or divided between the clamps, and suture-ligated.
  • 21. 5. Trachea is fixed with a hook and opened with a vertical incision in the region of 3rd and 4th or 3rd and 2nd rings. This is then converted into a circular opening. The first tracheal ring is never divided as perichondritis of cricoid cartilage with stenosis can result
  • 22. Confirmation of trachea • 5 ml syringe containing 4 % Lignocaine taken, its needle inserted into trachea & aspirated. Air bubbles confirm presence of needle in trachea. • 2 ml of solution injected into trachea & needle removed quickly to avoid breaking of needle during violent cough movements.
  • 23. 6. Tracheostomy tube of appropriate size is inserted and secured by tapes Lubricated tracheostomy tube inserted into trachea Confirm presence of tube in trachea with help of ambu bag & auscultation
  • 25. Jackson’s metallic tube • Made of German silver (alloy of Ag + Cu + P) • Has obturator (pilot), inner tube & outer tube • Inner tube is longer than outer tube for its removal & cleaning. Outer tube maintains patency. Pilot is inserted into outer tube for smooth & non-traumatic insertion of tube • Lock prevents expulsion of tube during cough
  • 27. Fuller’s metallic tube • Outer tube bi-valved. The 2 blades when pressed together, help in smooth entry of tube. • Inner tube is longer & has a vent for phonation • Pt phonates by closing main tube opening • Vent also helps in decannulation of tube
  • 29. Portex cuffed tube • Made of siliconized Poly Vinyl Chloride. It is thermolabile & prevents crusting. • Low pressure high volume cuff maintains an air-tight seal required for:  Prevention of aspiration of secretions  Positive pressure ventilation
  • 31. Portex uncuffed tube For tracheostomy patient receiving radiation
  • 32. TYPES OF TRACHEOSTOMY TUBES • Plastic or metal • Cuffed or uncuffed • Fenestrated or unfenestrated • Double canula or single canula
  • 34. 7. Skin incision should not be sutured or packed tightly as it may lead to development of subcutaneous emphysema. 8. Gauze dressing is placed between the skin and flange of the tube around the stoma
  • 35. 9.Tapes of tracheostomy tube tied around the neck keeping a space for 1 finger. Neck kept flexed. Skin incision closed loosely to avoid surgical emphysema.
  • 36. Insertion of medicated gauze Betadine soaked gauze or Sofratulle put around the tracheostomy opening.
  • 37. Paediatric Tracheostomy -Soft and compressible trachea ,so difficult to identify and may get displaced & injure recurrent laryngeal nerve -Preferably in general anaesthesia -Don’t extend neck too much as pleura,innominate vessels,thymus may get injured -Post operative x-ray of the neck to know position of the tube -Use of soft silastic and portex tube
  • 38. Post Operative Care 1.Constant Supervision • For bleeding, displacement, blocking of tubes, removing secretions • Patient is given a bell or paper pad to communicate • Pt given 100 % oxygen. Deflate the tube cuff.
  • 39. 2.Suction • Suction catheter with negative suction pressure (10 -15 mmHg) used. • Catheter diameter should be < 1/3rd of internal diameter of tracheostomy tube • Catheter length introduced just enough to go beyond inner tube (10 cm)
  • 41. 3.Tracheostomy tube care • Inner tube is removed & cleaned when blocked • Outer tube never removed before 72 hrs to allow formation of tracheo-cutaneous tract • Cuff of Portex tube deflated for 10 minutes every 2 hours to prevent pressure necrosis & dilatation of trachea
  • 43. 4. Others • Chest auscultated for confirmation of adequate suctioning. Re-inflate cuff to a pressure of 25 mmHg. Patient oxygenated again. • Tracheostomy wound dressing done BID • Steam inhalation TID. Moist gauze piece placed over tracheostomy tube opening. Regular chest physiotherapy, expectorants & mucolytics given.
  • 44. 5.Prevention of crusting and tracheitis -Proper humidification using humidifier,nebulizer or keeping boiling kettle in room. -Using a few drops of ringer lactate or normal saline or hypotonic saline -Every 2-3 hrs
  • 45. Decannulation • Adult: plug or seal tube opening & if tolerated for 24 hrs, remove tube. • Child: Sequentially reduce size of tube. After tube removal  close wound. Healing occurs within 1 week. Secondary closure after freshening the wound margin is required rarely. • Infant or a young child -Decannulate in operation theatre -Equipment for re-intubation should ne available like good headlight, laryngoscope, proper sized endotracheal tubes and a tracheostomy tray -After decannulation observe for respiratory distress,t achycardia, colour. -Oximetry is useful
  • 47. Decannulation difficulty Organic causes • Persistence of cause requiring tracheostomy • Obstructing tracheal granulations • Tracheal oedema • Subglottic stenosis • Collapse of tracheal wall (tracheomalacia) Non-organic causes: • Emotional dependence in children • Inability to tolerate upper airway resistance • In-coordination of laryngeal opening reflex • Long-standing tube leads to impaired laryngeal development
  • 48. Complications of tracheostomy 1. Immediate Complications (During tracheostomy) 2. Intermediate Complications (Few hours or days later) 3. Late Complications (Due to prolonged use of tube for weeks-months)
  • 49. Immediate complications • Haemorrhage • Aspiration of blood • Injury to recurrent laryngeal nerve • Injury to apical pleura (Pneumothorax) • Injury to oesophagus (May cause tracheoesophageal fistula) • Apnoea (Due to Carbondioxide wash out)
  • 50. Intermediate Complications • Haemorrhage • Displacement of tube (Due to use of improper size tube) • Blocking of tube (Due to excessive crusting/poor humidification) • Subcutaneous emphysema • Tracheitis/Tracheobronchitis with crusting in trachea • Pulmonary infections (Due to compromised airway defense mechanism) • Wound infection & granulation
  • 51. Late Complications • Haemorrhage (Due to erosion of major vessels esp innominate/bracheocephalic art) • Laryngeal stenosis (Due to perichondritis of cricoid cartilage) • Tracheal stenosis (Due to tracheal ulceration & infection) • Tracheoesophageal fistula (Due to erosion of trachea by tip of the tube) • Persistent tracheocutaneous fistula • Keloid/Unsighty scar at tracheostomy site • Difficult decannulation
  • 53. Procedure for immediate airway management 1. Jaw thrust • Lifting the jaw forward & extensing the neck • Improves airway by displacing the soft tissues • Avoided in spinal injuries
  • 54. 2. Oropharyngeal airway • Displaces the tongue anteriorly & relieves soft tissue obstruction • Face mask can also be kept
  • 55. 3. Nasopharyngeal airway (Trumpet) • Inserted transnasally into posterior hypopharynx • Releives soft tissue obstruction caused by tongue & pharynx
  • 56. 4. Laryngeal mask airway • It is a device with a tube & a triangular distal end which fits over the laryngeal inlet • Oxygen can be delivered directly into the trachea
  • 57. 5. Transtracheal jet ventillation • An IV cathether with a syringe is inserted into the cricothyroid membrane & directed caudally. • Then the needle is withdrawn leaving the catheter in position & jet ventillation is started
  • 59. 6. Endotracheal intubation • Larynx is visualized with a laryngoscope & endotracheal tube is inserted • Helps to avoid a hurried tracheostomy in which complications are likely • After intubation, an orderly tracheostomy can be performed.
  • 60. 7. Cricothyrotomy/Laryngotomy/Mini tracheostomy • Opening of airway through cricothyroid membrane • Done only to buy time to allow patient to be carried to OT • Complications– Perichondritis,Laryngeal stenosis, Sub glottic edema
  • 61. Percutaneous Dilational Tracheostomy •A minimally invasive alternative to conventional tracheostomy. •Advantages: No need of OT, thus is cost effective. Forms a stoma between tracheal rings, resulting in reduced blood loss as there is usually no disruption of blood vessels. •Avoided in patients who are obese, have neck mass, difficult to intubate, difficult to extend neck, larynx & trachea aren’t easily palpable
  • 62. • Steps: 1. Neck is extended & incision is given 2cm below the lower border of cricoid 2. Trachea is exposed & thyroid isthmus is pushed down 3. Bronchoscope is inserted to monitor the passage of needle,guide wire & dilator which are passed into trachea between 2nd & 3rd tracheal ring. 4. After dilatation tracheostomy tube is inserted.