Components of a standard tracheostomy tube Following Successful Liberation From Prolonged Mechanical Ventilation Absence of distress and stable arterial blood gases on prolonged mechanical ventilation for 5 days Stable clinical condition indicated by factors such as: 1Hemodynamic stability 2Absence of fever, sepsis, or active infection 3PaCO2 60 mm Hg 4 Normal endoscopic examination or revealing stenotic lesions occupying 30% of the airway 5 Absence of delirium or psychiatric disorders 6 Adequate swallowing evaluated by gag reflex, blue dye, and video fluoroscopy 7 Patient able to expectorate on request 8 Maximum expiratory pressure 40 cm H2O ComplicationsNo. ofcasesPercent ofTotal Outcome Tracheal stenosis 21 1.85 Hemorrhage 9 0.87 Tracheocutaneous fistula 6 0.53 Infection 5 0.44 Pneumothorax 3 0.26 Tube decannulation/obstruction 1 0.08 Subcutaneous emphysema 1 0.08 Tracheoesophageal fistula 1 0.08 directly proportional to length inversely proportional to the radius of the tube raised to the 4th power (when flow is laminar) When flow becomes turbulent, airways resistance becomes inversely proportional to the radius of the tube raised to the 5th power. small reductions in tube radius result in large increases in resistance. Turbulent flow occurs when flow rates are high, when secretions adhere to the inside of the tube and because of tube curvature. The word tracheostomy is derived from 2 Greek words meaning “I cut the trachea.” ENDOTRACHEAL Size ID length 6 6 31 7 7 34 8 8 35 8.5 8.5 36 mm cm TRACH Vd 11 15 18 24 ml Size 4 6 8 10 ID 5 7 8.5 9 mm length Vd 10 3 12 5 12 6 12 8 cm ml Tracheostomy tubes have an important effect on respiratory physiology. The most recent and methodological robust studies indicate that these tubes reduce resistive and elastic WOB when compared to ETTs. This is a result of tracheostomy tubes lessening inspiratory and expiratory airways resistance and intrinsic PEEP. Before tracheostomy Vt ml 329 Ve l/m 9.2 F b/m 28 PEEPi cm/h20 2.9 PTP cm/h20xs/min 236 WOB J/L .97 WOB J/min 8.9 Exp RAW 9.4 After tracheostomy p 312 0.47 8.1 0.26 26 0.51 1.6 0.02 155 0.09 .81 0.09 6.6 0.04 6.3 0.07 20 surgical patients 14 men Mean age 58 Acute lung injury Ventilate mean 16 days Met extubation criteria Failed extubation twice before trach decision 80% had #8 ETT 20% #7 ETT Measurements: 6-8 hours before and 12 hours after surgical trach. THE 2ND TRACHEAL RING IS DIVIDED LATERALLY AND THE ANTERIOR PORTION REMOVED INSTEAD OF RESECTING AND REMOVING THE TRACHEAL RING, IT CAN BE USED TO CREATE A FLAP, WHICH CAN BE ATTACHED TO THE SKIN. THIS METHOD, DESCRIBED BY BJORK., FIBEROPIC BRONCHOSCOPY IS USED TO HELP PLACE THE GUIDE WIRE CORRECTLY FOR PDT. HERE THE WIRE IS SEEN IN THE ANTERIOR PART OR THE TRACHEA, PASSING BETWEEN THE 2ND AND 3RD TRACHEAL RINGS. HERE IS THE BRONCHOSCOPIC VIEW OF THE TIP OF A DILATOR ENTERING THE TRACHEA OVER THE GUIDE WIRE DURING PLACEMENT OF A PERCUTANEOUS DILATIONAL TRACHEOSTOMY. A SERIES OF TAPERED DILATORS ARE SEQUENTIALLY INSERTED OVER THE GUIDE WIRE TO CREATE THE STOMA FOR PLACEMENT OF THE TRACHEOTOMY TUBE. THE BLUE RHINO IS A SINGLE DILATOR THAT CAN BE USED INSTEAD OF THE SEQUENTIAL DILATORS OF THE CIAGLIA METHOD The Rig Veda, sacred book of Hindu medicine, written between 2000 and 1000 BC. The Ebers Papyrus, dating from about 1550 BC. The Ebers Papyrus is written in hieratic Egyptian writing and preserves for us the most voluminous record of ancient Egyptian medicine known. The ancient Chinese text Huang Ti Nei Ching Su Wen contains no reference to any surgical procedure. In the 8th century BC, Homer is said to have described the relief of choking persons on cutting into the trachea. Hippocrates (4th century BC) may have referred to tracheal cannulation as a treatment for quinsy (peritonsillar abscess). Alexander the Great, in the 4th century BC, “punctured the trachea of a soldier with the point of his sword when he saw the man choking from a bone lodged in his throat.” Both Aretaeus and Galen, in the 2nd Century AD, wrote that Asclepiades of Bithynia performed elective tracheostomy in around 100 BC. McClelland RM Galen, the most eminent Greek physician after Hippocrates. Antyllus of Rome told in AD 340 of making a transverse incision between the 3rd and 4th tracheal rings, drawing the cartilages apart with hooks, and subsequently sewing the edges of the wound together once the patient could breathe more freely. Frost EA Antyllus', a 4th century Roman physician. The first account of the procedure to be written by the surgeon who performed it was by Brasavola in 1546, who used it to relieve airway obstruction from enlarged tonsils. McClelland RM Antonio Musa Brassavola (variously spelled Brasavoli, Brasavola, or Brasavoli, born January 16, 1500 in Ferrara) was an Italian physician and one of the most famous of his time. At about the same time , Fabricius ab Aquadependente is said to have performed a tracheostomy on a patient with a foreign body in the larynx , as well as on several other occasions. Frost EA The first step towards percutaneous tracheotomy was made by the famous Italian anatomist and surgeon Fabricius of Aquapendente ( 1537-1619). Sanatorius , in 1590, first used a trocar for tracheostomy, and reported leaving a cannula in place for 3 days. Frost EA The Italian surgeon Sanctorio Sanctorius (1561-1636) was probably the first surgeon to describe percutaneous tracheotomy (Sanctorius, 1626). The word tracheostomy was first used by Heister in 1739 (German surgeon Laurentius Heister(1683-1758). George Washington, who died in 1799, developed progressive upper-airway obstruction, the cause of which is thought most likely to have been acute epiglottitis. Scheidemandel HH. Did George Washington die of quinsy? Arch Otolaryngol 1976;102(9):519–521.5. Witt CB Jr. The health and controversial death of George Washington. Ear Nose Throat J 2001;80(2):102–105. The prominent physician Elisha C Dick, who examined the former president, recommended tracheostomy, but was overruled by the other physicians in attendance. Frost EA. Tracing the tracheostomy . Ann OtolRhinol Laryngol 1976;85(5 Pt 1):618–624. Witt CB Jr. The health and controversial death of George Washington Ear Nose Throat J 2001;80(2):102–105. In the early 19th century, performance of the procedure became more widespread and there were multiple reports in the medical literature. Trousseau reported in 1869 on 215 patients in whom tracheostomy was performed in the treatment of diphtheria (with 47 survivors), his series having begun during the 1830s. The 1860 yearbook of the New Sydenham Society contained some 38 papers devoted to indications and techniques of tracheostomy. In this country,the famous surgeon Chevalier Jackson refined the technical aspects of the procedure and described them in detail in 1909. Chevalier Jackson standardized the indications for tracheostomy, the technique itself, and the instruments used, around the turn of the 20th century. He developed anatomically correct tracheostomy tubes, recommended a“high” tracheostomy location (ring 2 or 3). 1. Merriam-Webster Online Dictionary: • Tracheostomy: the surgical formation of an opening into the trachea through the neck especially to allow the passage of air • Tracheotomy: the surgical operation of cutting into the trachea especially through the skin 2. Stedman’s Medical Dictionary: • Tracheostomy: An operation to make an opening into the trachea. • Tracheotomy: The operation of incising the trachea, usually intended to be temporary 3. Oxford English Dictionary:• Tracheostomy: The operation of making an opening in the trachea near its upper end, so that the patient can breathe through it; also, the opening so made • Tracheotomy: = tracheostomy administer positive-pressure ventilation provide a patent airway provide protection from aspiration Airway protection in head injured or comatose patient and in postoperative neurosurgical patients provide access to the lower respiratory tract for airway clearance 1. 2. 1. 2. 3. 1. a) b) 1. 2. ID OD Curve Angled Curved Length Xl proximal Xl distal normal Cuffed Low pressure Fenestrated Non-fenestrated Tight to shaft Foam Uncuffed Shiley uses the Jackson scale most of the time (xl and SCT uses ISO) w/IC #4 = ID= 5.0, #6= ID 6.4, #8= ID 7.6 , #10= ID 8.9mm. Portex uses the International Standards Organization (ISO) scale. Median –measure at shaft. The functional internal diameter size. Subtract 1mm for inner cannula. w/o IC #6= ID 6mm, #7 =ID 7mm, #8= ID 8mm the rigid cricoid cartilage encases a 1.5–2.0-cm region known as the subglottic space. Inferior to cricoid is the trachea, a cylindrical tube that extends inferiorly and slightly posteriorly. The trachea is made up of 18–22 C-shaped rings consisting of rigid cartilage anteriorly and laterally, and a membranous posterior portion. In the average adult, the distance from cricoid to carina is approximately 11 cm in length, with a range of 10–13 cm. #4 11.47 cm H2O/L/s #6 3.96 “ #8 1.75 “ #10 0.69 Mullins JB, Templer JW, Kong J, Davis WE, Hinson J. Airway resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993;103(12):1367–1372 SHAPE C U D E T O #MALE 14 33 16 21 16 0 #FEMALE 38 10 6 45 0 1 The tone of the trachealis muscle that bridges the gaps posteriorly between rings is responsible for the shape differences. 1.Reduced dead space 2.Less airway resistance 3.Decreased work of breathing 4.Better secretion removal with suctioning 5.Less likelihood of tube obstruction 6.Improved patient comfort 7.Less need for sedation 8.Better glottic function, with less risk of aspiration 9.Ability to move patient out of the intensive care unit 10.Changes in clinician behavior Inner Diameter 6 7 7.5 8 8.5 9 Outer Diameter 9.2 10.5 11.3 11.9 12.6 13.3 Length 64.5 70 73 75.5 78 81 Can be used with Perc kit. Markings line up. 1. 2. 3. 4. 5. Pathologic correlates for hypoxemia Low inspired O2: high altitude, smoke inhalation. Alveolar hypoventilation: COPD acute exacerbation, Acute asthma exacerbation, neuromuscular weakness. Ventilation-perfusion mismatch: COPD exacerbation, asthma exacerbation, mild CHF, mild pna, mild atelectasis. Shunt, right to left: severe exacerbation COPD/asthma, severe CHF/pneumonia/atelectasis, ARDS. Diffusion defect: acts a a V/Q mismatch. Work this table back and forth to determine FIO2 change and device change. Low flow vs high flow; aka variable O2 devices vs fixed O2 devices. A)The amount of oxygen (FiO2) desired (*This is the fundamental consideration.) B)The degree of FiO2 precision required. (*The Venturi mask is the mask of choice for “CO2 retainers”.) C)Patient comfort and compliance. D)The need for aerosol mist. 1) Most commonly used device because of excellent patient tolerance. 2) The delivered oxygen at any flow setting depends primarily on the patient’s ventilatory pattern. 3) Can deliver from 24 – 40% oxygen and is ordered at flows of ¼ to 6 liters per minute. 4) Humidification should be used for flows greater than 4L/minute. (*Exceptions: Humidification for flow rates <4L/min may be considered if the patient requests it, if the patient experiences epistaxis, or if the patient complains of a dry nose, dry secretions, and/or a sore throat.) 1) A reservoir bag is added to the simple mask design to deliver over 60% oxygen (from 60-80% oxygen). 2) A Non-Rebreather Mask is used and the 2 flaps are removed to create a Partial Non-Rebreather Mask. 3) The system allows the first part of the patient’s exhalation to enter the bag (anatomic dead space gas). 4) The reservoir bag should NOT deflate completely on inspiration. If this occurs, the patient may rebreathe his or her own CO2. 5) Partial rebreathers should always run at about 10 liter/minute to prevent total collapse. 1) The use of valves in the non-rebreather mask allows for one way flow of 100% oxygen into the reservoir bag and then out to the patient with no rebreathing of expired gas. 2) This delivery system is used when one needs to deliver a high percentage of oxygen quickly. 3) Flow rates of 10 – 15 liters per minute theoretically provide the patient’s entire inspired volume. 4) Increased respiratory drive along with improper seal of the mask may all for room air to be inspired. 6) The non rebreather mask contains 2 valves. Check labeling to be sure valves are latex free.