Tracheostomy
By Ussana Promyothin MD.
Tracheostomy
• Surgical opening in the trachea for ventilation
Indication
• Bypass upper airway obstruction
• Clearance secretion at lower respiratory
• Prevent aspiration gastric content in absent of laryngeal reflex
Other indication
• Prolong intubation(1-3wks)
children more prolong
• Laryngeal injury
• Fracture face neck area
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Also
Improved oral hygiene
Oral movement for communication
Reduction damage larynx,nose ,mouth
Contraindication
• Prolong bleeding
• On anti-coag, anti-pletlet medication
• Elective tracheostomy
• Emergency tracheostomy:
should avoid, expertised surgeon,team
• In children: perform only with a secured airway
either from ET tube or bronchoscope in OR
• Emergent tracheostomy should be avoided if
possible
• Risk to vascular,lung and uncontrolled airway
Hyperextend the neck,
2 FB above thyroid notch ring 2,3
Skin incision,horizontal /vertical
Find white line,Test tracheostomy cuff
Clean trachea,aspirate air then push xylocaine
Stay suture,open trachea by inverted U
flap,cross,vertical
(in children stay suture on both sides of incision)
Standby tracheal dilator,suction,
Post operation care
• Irrigation with saline and suction q 15 mins
• Suction not exceed 15 seconds (block airway and
suck Oxygen out)
• Humidification Oxygen
(decrease thick mucus)
• Observe bleeding and subcutaneous
emphysema
• Off packing 24-48hrs
• Left tube in place 5-7 days
• Stitch off and off stay suture 7th day
• Blow Cuff when on ventilation or prevent
aspiration
• Not exceed 25 cm H2O
• Clean inner tube
• analgesic
Complication
Immediate
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Apnea :loss hypoxic drive,COPD  ventilator
Post obstructive pulmonary edemaPEEP
Pneumothorax chest x-ray post op
Injury to adjacent organ:thyroid ,vessel,
esophagus,recurrent laryngeal nerve
Pneumothorax
Early
• Bleeding HT, skin,thyroid,soft tissue
• Mucus inner tube
• Tracheitis humidification, minimize FiO2,
Stabilize tracheostomy
• Cellulitis: wound care,antibiotic
• Displacement: pass E-T tube, NG tube
Late
Bleeding
-innominate vessel:usually in 2wks,high mortality
(low tracheostomy,mobilized tracheostomy tube,high pressure
cuff,local infection)
-granulation( stroma, tip of tube)
Tracheoesophageal fistula:risk in retain NG tube
Type of Tracheostomy
Type/descr permanent
iption
ventilator Inner
tube
size
jackson
yes
no
yes
4-5
shiley
yes
yes
yes
4-6-8
portex
no(7-14days)
yes
no
7-8
blueline
no(1month)
yes
yes
7-8
Cricothyrodotomy:maneuver to buy
time
Advantage
• Near skin and less dissection
Disadvatage
• Trauma to subglottic area
• Contraindication:children<12 yrs,infection at
larynx,laryngeal trauma and risk transecting tumor
Tracheostomy care
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Clean skin around stroma
Change gauze
Clean inner tube
Aware obstruction or slip out of tube
Weaning tracheostomy tube
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Reason for tracheostomy has resolved
Stable lung status(O2<40%)
Effective swallow,gag,and cough reflex
Adequate nutrition, sleep, psychososial
suppor
• Cuff deflate trial
Method
• Flexible bronchoscope or IDL
• Assess cord movement,granulation,stenosis
area
• Admit,size tube down
• Plug tube day,all day night
• Off tube,observe before discharge
Epistaxis
Abnormal bleeding per nose
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Cause
Trauma ,nose picking ,nose blowing
URI, allergic rhinitis
Septum deviation
Decongestant ,nasal spray
Foreign body
Tumor
Post surgery
• Hypertension, artherosclerosis
• Anticoagulation drug,ASA,NSAID
• Decrease plt
• Liver function disease
Site of bleeding
MANAGEMENT
• Immediate evaluation :vital sign,airway
• Stop bleeding
• Compress nose,cold pack
Anterior epistaxis
• Little’s area region
• Ephridine or adrenaline pack (vasoconstrict agent)
• Beware in HT
• CAUTERIZATION
• 30%TCA,silver nitrate, electrical cautery
• Gel foam
Anterior nasal packing
Nasal speculum
Headlight
Suction
Anterior nasal packing
• Vasaline gauze or coated with antibiotic ointment
• Apneanaso-vagal reflex
bradycardia,hypotension
• Remove packing 2-4 days later
• Antibiotic and decongestant
Posterior nasal packing
Foley catheter
Posterior nasal packing
Anterior and posterior nasal packing
• Posterior packing :oxygen face mask
• Elevate head 30 degree
• Antibiotic cover Staph aureus
• Liquid diet
• Remove packing 3-5 day later
• If high fever ,hypotension, remind toxic shock
syndrome
• Surgery
• Ligation artery
• Endoscopy
•Angiogram and embolization
Sinusitis
Anatomy and function
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Resonance to voice
Humidify and warm air
Increase the area of olfactory
Absorb shock to head
Keep nasal chamber moist
Protect thermal to brain
Contribute facial growth
Lighten bone of skull
Acute bacterial sinusitis
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Cause
URI,AR
Dental infection
Obtruction ostium: structure,tumor
Immotile cilia
Foreign body: NG tube
Symptom
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Fever
Maxillofacial pain
Dental pain
Otalgia
Posterior nasal drip
Nasal congestion
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Causative agent
viral
S.pneumoniae
H.influenzae
M.catarrhalis
Other bacteria
Fungus
FILM SINUS
Management
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Proper antibiotic
Systemic decongestant:maxiphed
Beware: HT, Heart disease, urinary retention
Topical decongestant: not exceed 3 days
Mucolytic agent
Antihistamine if suspected allergy
Normal saline irrigation
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If failure medication
Antral puncture
For drainage and C/S
CHRONIC BACTERIAL SINUSITIS
Greater than 12 wks duration symptom
Treatment: antibiotic 4-6 wks
CT scan
Surgery : ESS (endoscopic sinus surgery)
ESS
Complication sinusitis
• Mucocele
• Orbital complication: cellulitis abscess
• Intracranial complication: meningitis
brain abscess