Tracheostomy

Dr. Roshana Mallawaarachchi

BJA Education, June 2015

03/07/2015

History
One of the oldest surgical procedures.
Antonio Musa Brasavola

o Italian physician

o 1st (well documented) successful tracheotomy, 1546

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What is Tracheostomy?
Tracheostomy
o Creation of a stoma at the skin surface, which
leads to the trachea.

Anatomy

Anatomy

Anatomy

Anatomy

Indications
Maintain airway
o Upper airway obstruction
o Actual & potential obstruction

Facilitate removal of bronchial

secretion
o Poor cough effort with sputum retention

Protect the airway from aspiration

o Neuromuscular disorders, unconscious, head injuries, strokes

Mechanical ventilation
o Acute ICU, chronic hospital/community

Facilitate weaning from artificial

ventilation

Comparison - Advantages
Tracheostomy

Need for sedation

Damage to glottis

WOB

Patient comfortable

Weaning easier

Endotracheal intubation

Easier & quicker to perform

Well tolerated for short

periods

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Comparison - Disdvantages
Tracheostomy

Endotracheal
intubation

Invasive procedure

Unpleasant to tolerate

Bleeding & airway loss during

procedure

Prolonged sedation

Stoma infection or breakdown

Difficult to re-institute
respiratory support without reintubation

Scarring, tracheomalacia,
stenosis

Weaning more difficult after a

long period of placement

Blockage & displacement

Upper airway trauma

Damage to adjacent
structures

Damage to vocal cords

Swallowing difficulties

Breaches larynx, risks

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Physiological effects

Dead space, WOB

Humidification, filtration lost
Mucus collection
FB reaction local inflamation
Speech affected
Swallowing affected
Altered body image
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Features of Tubes
Diameter

Cuff

Inner tube

Features of Tubes
Fenestration

Flexibility

Adjustable flange

Features of tubes
Subglottic suction
Speaking valve

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Different airflow patterns

Types of tracheostomy
Temporary or long term/permanent
Emergency or elective procedure
Method of insertion
o Surgical
o Percutaneous

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Types of tracheostomy
Temporary
o Acute resp support, protection, Head Injury, neurological
dis, maxillofacial/ENT procedures

Permanent/Long term
o Chronic resp support, CA nasopharynx / larynx

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Emergency
tracheostomy

Elective tracheostomy

Techniques for insertion

Open Surgical
o OT
o ENT/Trauma Sx

Percutaneous (PCT)
o ICU
o Anaesthetist/Intensivist

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Different techniques
Horizontal slit - a horizontal or T-shaped opening

Window. Removal of small anterior portions more permanent stoma window

Vertical slit - A U- or H-shaped opening, flaps

tacked to skin edges with absorbable sutures
(1wk) -semi-permanent stoma . Most modern
adult surgical tracheostomies

Percutaneous Tracheostomy

Percutaneous Tracheostomy
ICU - CA/intensivist (minimum 2 trained medical
practitioners)
Simple, quick, bedside - anaesthetic sedation +LA
Guided by surface anatomy
Needle through the neck (fibroelastic tissue
joining trach rings) into the trachea guidewire through the needle.
Higher approach/lower approach
Needle is removed dilate over the wire
2 techniques
o Ciaglia serial dilatational technique
o Griggs - Guidewire dilating forceps method (GWDF)
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Percutaneous Tracheostomy
Secured by cloth ties, sutures or a holder.
o Less dissection, cutting than with a surgical technique
o Less tissue trauma and bleeding. (if bleeding sx trach
diathermy/ligation)

To ensure correct needle placement - guided by

fibreoptic endoscope
Immediate post op CXR, bleeding, sx
emphysema, patency, pain relief

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Advantages of using fibereoptic endoscope

1. Confirmation - entry point - anterior trachea. B/w 11 and 1
oclock is ideal, although the closer to 12 oclock, the better

2. Confirms- entry site b/w 2nd & 3rd tracheal rings. tracheal ring
fracture.

3. Avoid posterior tracheal wall damage & paratracheal or

oesophageal insertion.
4. Ensure guidewire placement.
5. Successful placement in the lumen
6. Allows aspiration of blood promptly from the airway

Correct placement of a needle and

guidewire within the trachea.
oclock)

A puncture site that is

lateral (towards 3

Drawbacks in using a Bronchoscope

Need ETT atleast size 7mm ID Hypoventilation!
Damaging endoscope with initial puncture into
trachea.

 The tract take 7-10 days to mature but 2-4

days for a surgical tracheostomy.
If displaced early period, tissues spring back
into their original places, but surgical tract
usually sutured more likely to remain patent.
A tracheostomy tube should not be changed for
7-10 days.

Contraindications

Coagulopathy
Difficult anatomy
Proximity to the site of recent trauma / Surgery
Potential for aggravated morbidity
Severe gas exchange problems
Age < 12 (PCT)

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Complications

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Care of the
Tracheostomy Tubes

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Essential equipment bedside

Operating suction
Suction Catheters
Gloves, eye protection
Spare Trach tube same size
Smaller Trach dilators
Rebreathing bag
Catheter mount
Trach holders, dressing
10ml syringe
Artery forcep
Resus equip (ambu, ETT, laryngoscopes, drugs)
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Humidification
Artificial humidification - mandatory !
Inadequate humidification physiological
changes - serious and potentially fatal, including:

Retention of viscous, tenacious secretions

Impaired mucociliary transport
Inflammatory changes and necrosis of epithelium
Destruction of cellular surface of airway causing
inflammation, ulceration and bleeding
Reduction in lung function (e.g. atelectasis/ pneumonia)
Increased risk of bacterial infiltration.
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Methods of artificial humidification

Saline Nebulisation
the viscosity of secretions - easier to remove by suction or
cough.
5 to 10mls 0.9% sterile saline - 2-4 hourly or as required.
flow rate of 6-8 litres/minute - oxygen or air.
Heat Moisture Exchanger (HMEs)
changed at least every 24 hours
Heated Humidification
Cold Humidification

Mucolytics
Hypertonic saline or acetylcysteine (via nebuliser), carbocisteine
(via mouth) or DNA-ases such as dornase alfa
(used in conditions such as cyctic fibrosis)

Stoma filters or bibs

Contains a foam layer which absorbs moisture from pts expired
gases.

Hydration
Enteral, intravenous or even subcutaneous.

Other methods of improving secretions

Mobilization
will help to improve the clearance of secretions

Suctioning
Indications
Noisy and or moist respirations
Increased respiratory effort
Prolonged expiratory breath sounds
Restlessness
Reduced oxygen saturation levels
Increased or ineffective coughing
Increased use of intercostal muscles
Patient request
More sinister signs of airway obstruction such
as hypoxia and Cardiovascular changes
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The type of suctioning

Open
Closed changed 72hrs
Suck oral cavity aswell.
Preoxygenate prior to suctioning (esp O2 dependent)

Suction catheter selection

too large damage, occlude the tracheal tube hypoxia.
diameter of the catheter should be not more than half the internal
diameter of the tracheal tube.
(Size of endotracheal or tracheostomy tube 2) x 2 = Correct
French G

The frequency of suctioning

Tracheal suction at least once per 8 hours.
Failure to pass a suction catheter Red Flag - Blocked or
Displaced
prompt assessment by an appropriately trained individual .

The depth of suctioning

1. Shallow suctioning
2. Deepsuctioning
Advancing the suction catheter through the tube until it
reaches the carina (resistance) 10-15cm
Pressure : < 100-120 mmHg
The catheter should then be withdrawn slightly
before suction is commenced (Guidelines 2013)
Duration: Max 10 sec
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Management of the inner

cannulae
Remove and inspect
at least once per 8 hour shift
if the patient shows any signs of respiratory
distress.
For a patient undergoing mechanical ventilation, it may not be
safe to repeatedly disconnect the ventilator circuit and change
the inner tube routinely.
Cleaning or changing an inner tube should always represent the
best balance of risks to the patient.
- Position neck extended
- Preoxygenate, Suction
- Sterile technique
- Remove sterile NS or water - dry
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Cuff management
Management of the distal cuff.
Tracheal capillary pressure 20-30mmHg
Impairment of this blood flow - between 2237mm Hg.
Pressure should be kept between 1525cmH2O (10-18mm Hg).
Regular cuff pressure checks are carried out
every 8 hour shift

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Stoma care
Inspect daily, clean daily
Pus swab culture

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Oral care
Preventing healthcare associated infections.
Dental plaque and the oropharynx can become colonized
by bacteria and a biofilm can develop on the inside of
airway devices.
Secretions can also pool in the subglottic region.
Encourage self-care when possible
Patients teeth should be brushed with toothbrush and
toothpaste at least twice a day.
Chlorhexidine mouth washing twice per day (not
immediately after tooth brushing)

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Changing Tubes
Indications to change a tracheostomy tube
- The tube in-situ: max. recommended duration: (ICS
guidelines)
Removable inner cannula - 30 days
Single lumen tubes - 7-10 days
- Facilitate weaning - inserting a smaller, un-cuffed or
fenestrated tube
- The patient needs ventilatory support or resuscitation
and requires a change from an un-cuffed to a cuffed tube
- To improve fit or comfort of tube
- To replace a faulty tube
- To resolve a misplaced or displaced tube
DONOT change within 72 hours, ideally not for 7 days
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Elective change of a tracheostomy tube

2 techniques:
1. A blind technique where the new tube is
inserted directly into the old stoma
2. A guided technique using a wire or bougie to
remove the old tube over and to railroad the
new tube over.
.Pre-oxygenation
.Positioning
.Suck out secretions prior to cuff deflation.

Weaning & Decannulation

Multidisciplinary assessment

Absolute requirements
o Patent upper airway
o Spontaneous cough
o Ability to swallow secretions

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Checklist before weaning

Is the upper airway patent? (may require endoscopic
assessment)
Can the patient maintain and protect their airway
spontaneously?
Are they free from ventilatory support?
Are they haemodynamically stable?
Are they absent of fever or active infection?
Is the patient consistently alert?
Do they have a strong consistent cough (able to cough into
mouth)?
Do they have control of saliva + / - a competent swallow
Are there any planned procedures requiring anaesthesia
within next 7-10 days?
Can we safely support the weaning process in the patients
current clinical environment?

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Weaning

1.
2.
3.
4.

Cuff deflation
One-way valve to achieve 24 hr deflation
Tolerate a Cap?
Decannulation

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A patient with a
tracheostomy suddenly
desaturates!
How do you proceed?

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References
Tracheostomy management: Katharine Hunt, BJA
Education, 15 (3): 149153 (2015)
College of Anaesthesiology (Sri Lanka) Guidelines:
Nov 2013
Ohs Intensive Care Manual 6th edition

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Questions
August 2012 SAQ
2.
(a) What are the indications (25%) and
contraindications (20%) of percutaneous
tracheostomy (PCT)?
(b) List the potential complications of PCT. (55%)

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Questions
FRCA May 1997
(a) What are the indications for performing a
tracheostomy?
(b) List the complications of tracheostomy.

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Questions
You have been called urgently to attend a ventilated
patient on the ICU who has become acutely agitated,
hypertensive and profoundly hypoxic. A percutaneous
tracheostomy was performed 18 hours ago and is
being weaned from ventilatory support .
a) List possible causes for this patients acute hypoxia.
(25%)
b) What clinical features support an airway problem?
(40%)
c) How would you manage an airway problem in this
patient? (35%)
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