Tracheostomy: Trachea, procedures, advantages and complications (Week 2)

Tracheostomy

formation of an opening into the trachea or the opening its self

Tracheotomy

procedure to create an opening into the trachea

Where does the trachea start?

Just below the larynx

• C6

Where does the trachea end?

Carina (under the junction of the sternum)

• T4

Trachea receives blood supply from the…

• Brachiocephalic

• Inferior thyroid and bronchial

3 layers of the trachea

Outer layer = Fibrous elastic

Middle= cartilage

Inner = lined with ciliated columnar epithelial (needs cilia to clear secretions)

Nerve supply of trachea comes from?

• Parasympathetic

• Sympathetic

Is the trachea rigid or flexible?

Flexible

• has to accommodate any movement of head/neck and depth of breathing

Tracheal Measurments

Length= 12-16cm long (depends of size of thorax)

Width=

• women = 13-16mm

• men= 16-20mm

Tracheostomy explained simply

surgical opening into anterior wall of trachea to help ventilation

What are the 2 methods for tracheostomy

1. Surgical Tracheotomy (horizontal and vertical incisions made)

2. Percutaneous Dilation Tracheotomy (PDT)

Does a tracheostomy have to be done in OR?

No

Can be done in ICU at bedside or can be done in OR

Surgical Tracheostomy equipment

1. Sterile tracheostomy tray

2. Cautery equipment

3. Trach tube (make sure to check cuff, and have a size smaller available)

4. Surgical light

Surgical Tracheostomy prodecure (ICU bedside)

1. Medicate pt

2. Keep pt on vent

3. Increase FIO2 (pre oxygenate)

4. Monitor pts sats (HR, BP, SpO2)

5. Position pt (sniffers)

6. Clean anterior side of neck

7. Drape site (usually 2nd and 3 tracheal ring)

8. Paralyze pt

9. Dissection deep to trachea (below thyroid isthmus and above inferior thyroid veins)

10. Horizontal opening created into trachea then cut vertically till rings exposed

11. When rings are dissected and retracted: suspend ventilation, deflate ETT cuff, withdraw ETT until tip passes stoma

12. Insert trach tube and inflate cuff

13. Put back on ventilation or bagger

14. Confirm placement with ETCo2 and auscultation

15. Secure tube + remove ETT (**only remove once we have confirmed placement of trach tube)

16. Send for CXR

Percutaneous Dilation Tracheostomy uses what technique?

Seldingers technique

Which tracheostomy is most commonly used now?

PDT

What is Seldinger’s technique?

Uses guide wire to replace arterial catheters

PDT equipment

• Minor suture bundle (sterile towels and suturing instruments)

• PDT kit (Rhino dilator vs Griggs forceps)- these depend on surgeon preference

• Bronchoscope and light source

• Tray set up

• Trach tube (check cuff)

Which tracheostomy type uses a bronchoscope?

PDT

PDT procedure

1. Set up trach tray and bronch in pts room

2. Switch patient to bagger via bronch adaptor

3. Syringe attached to ETT pilot line

4. Cut ETT tapes

5. Bronch inserted to end of ETT (visualize carina)

6. Deflate ETT cuff and withdraw to just above trach insertion site (2,3 ring)

7. Injection site with lidocaine containing epinephrine

8. Large bore angiocath inserted between tracheal rings until can see with bronch

9. Needle removed from catheter and guide wire inserted into trachea

10. Insert dilator using guide wire

11. Dilate hole until can fit trach

12. Place trach tube (with help of obturator)

13. Once in remove guide wire

Complications of PDT

• Bleeding

• infection

• tracheal stenosis (narrowing)

• accidental extubation

• paratracheal insertion

• esophageal perforation

• subcutenous emphysema

• pneumothorax

• tracheal ring fracture

PDT benefits over surgical procedure

• procedure time shorter

• faster stoma closure

• lower risk of infection

• less scaring

PDT contraindications

• Can’t use for kids under 12

• faster to do surgery during emergency

• hemodynamic status

• anatomy

• BVs

• Infection

• Neck size or deformities

• Unstable (ventilatory perspective)

• Coagulopathy

What is the RT’s main role during PDT

provide BVT and secure ETT tube

Why would we do a tracheostomy?

• Upper airway obstruction

• prolonged resp/vent failure requiring prolonged airway and ventilatory support (most common)

• sleep apnea (not as much anymore)

• anything else that warrants need for it

Advantages of tracheostomy

• comfort/mobility

• Vd

• bypasses upper aw/glottis

• mucosal damage, vocal fold paralysis

• secretion clearance

• WOB (airway resistance)

• oral feeding

• can talk (phonation)

• stabilization

Tracheostomy general complications

• pneumothorax (5%)

• stomal hemorrhage (5%)

• infection

• subcutaneous emphysema

• accidental decannulation

• tube occlusion

• fistula

• vocal cord paralysis

Immediate (24hour) complications

• bleeding/hemorrhage

• pneumothorax

• air embolism

• subcutaneous and mediastinal emphysema

Later (24-48 hour) complications

Infection:

• epithelialization begins to form in 4 days

• febrile pt

• increased WBC

• inflammation response

Hemorrhage:

• wound itself

• tracheal wall

• secondary to tracheitis

• trach ties may be left for more than 1 day

The Feared ones…

1. Tracheal stenosis

• occurs at surgical site

• late complication (days to week after decannulation)

2. Accidental decannulation

• worst with the fresh trach

• failed recannulation attempt = problems

3. Tracheoesphogeal fistula:

• trachea ischemia secondary to tube pressure

• suspect if suctioning feeds from trach tube

4.Trach tube changes:

• increased risk of bleeding

• stoma may close rapidly

• should not be attempted 7 days post trach unless required

When to perform in ICU

• after a week of PPV with little chance of extubation in ensuing week

• increased risk of tracheal stenosis exists

• aspiration protection /secretion clearance required long term

• others (failed extubation)