Editing Tracheostomy

== '''Types of tracheostomy:''' ==

* Upper airway absent (after laryngectomy) - an end stoma
* Upper airway present

== '''Indications for tracheostomy:''' ==

* Need for prolonged mechanical ventilation (acute or chronic resp failure)
** Seems to be about day 10-14 after intubation currently
** Allows reduction in sedation
* Airway protection (neurologic catastrophe or copious/tenacious secretions)
* Upper airway obstruction
* Emergency tracheostomy when not possible to perform translaryngeal intubation

== '''Contraindications''' ==

* Absolute
** Overlying soft tissue infection
** Operator inexperience
** Inability to tolerate short apnoea
** Haemodynamic instability
* Relative
** Very high ventilator support settings
** Uncorrected coagulopathy (aim PLT > 50, INR < 1.6, not be on anticoagulants/antiplatelets)
** Laryngeal cancer prior to definitive treatment


== '''Choice of procedure''' (methods from Shields) ==

=== '''Percutaneous''' ===

** Favoured in most situations except emergencies
** Same complication rate as an open tracheostomy, and can be done bedside in ICU
** Do it under bronchoscopy guidance
** Prep as for open
** Visualise retraction of ETT to just below cords
** 22-guage needle into the intercartilaginous space between second and third rings
** J-wire fed through needle
** Horizontal 1cm incision centred on wire
** 14Fr dilation over wire
** Appropriate size dilator in the kit then inserted and the tracheostomy placed into airway
** Wire and dilator removed
** Flange sutured to skin

=== '''Open''' ===

** Check tracheostomy sizing and check cuff
** Supine with neck extended with shoulder roll, and slight reverse Trendelenburg
** Prep skin from nipple to mandible
** Pre-oxygenate and sedate
** LA
** Mark thyroid and cricoid cartilages with dots, and a 2cm transverse incision above the second or third tracheal ring, about 2cm below cricoid
** Divide subcutaneous tissues and platysma
** Retract strap muscles laterally to expose thyroid isthmus from first to fourth tracheal ring - blunt dissection in midline
** Move thyroid isthmus out of the way (usually second cartilaginous ring)
*** Dissect it off trachea with right angle
*** Ligate with 0 vicryl ties on either side
*** Divide in middle
** '''Check oxygen off and diathermy away'''
** Warn anaesthetist and incise trachea horizontally with 11 blade between the second and third rings - may need to use scissors too.
** Oropharyngeal tube out. Place new tracheostomy tube and inflate cuff, sometimes over a bougie. Check ventilation and that it is above carina. 
** Flange sutured to skin in all four quadrants (2/0 Prolene)
** Close any excess skin to provide a snug fit around the tube

=== '''Cricothyroidotomy''' (upper airway obstruction and unable to establish an oral airway OR for mini-tracheostomy to aid in removal of airway secretions) ===

** Prep as for open tracheostomy
** Palpate cricothyroid membrane (feel Adam's apple as thyroid cartilage, then move down to just below that, above cricoid cartilage)
** Make a horizontal incision directly over the cricothyroid membrane (can also do vertical, between sternal notch and hyoid)
** Lateralise strap muscles and trachea exposed
** Stabilise trachea/thyroid cartilage with non-dominant hand
** Horizontal cut in trachea using 10 (or 11) blade in the cricothyroid membrane
** Finger dilate
** Size 6 ETT


== '''Immediate issues''' ==

* Bleeding
** Most common source anterior jugular veins
** Ligate and divide if needed
** Ensure all bleeding controlled prior to incising trachea - hard to see after putting tracheostomy tube in
* Obese or large-necked patients may need a longer tube
* Air leak with ventilation - a self-inflating Bivona tracheostomy tube, or one with a longer cannula

== '''Tracheostomy management''' ==

* Humidification and regular suction
* Apply CCrISP algorithm if problems arise
* Don't change too soon - 3/7 post open, 1/52 post perc to ensure tract forms
* Should have inner canulae if on wards due to risk of blockage
* Routine changes
** Every 30-90 days
** 7-30 days post initial insertion
* Decannulation
** Indications
*** No upper airway obstruction
*** Ability to clear secretions that are neither too copious nor too thick
*** Presence of an effective cough
** Weaning
*** Progressive decrease in size of tracheostomy tube
*** Progressive capping trials until tolerated for 12, 24 or 48 hours
** Usual progression:
*** De-shield
*** Cuff down trial
*** Cuff down
*** Swallowing assessment
*** Consider decannulation
* Procedure
** Equipment
***
** Monitoring
** Supplemental oxygen via tracheostomy mask
** Neck extended slightly
** Suction
** Deflate cuff
** Remove tube
** Dress and occlude stoma
** Observe for signs of respiratory distress





Cuff: essential to provide PPV, also reduces risk of aspiration. Some traches don't have a cuff.

* Deflating cuff allows patient to breathe through mouth, and phonate (when they occlude the trache tube)

Inner cannula: allows the tube to be changed and cleaned without having to take the whole thing out

* However, it decreases the effective diameter of the tube, so they get more resistance to airflow.


== '''Common problems''' ==

* The most common complications are DOH! 
** Displacement
** Obstruction
** Haemorrhage
* Secretion buildup in tube - narrows effective diameter, leading to respiratory distress.

== '''Early complications''' ==

* Blockage/obstruction
** Presents with airway compromise
** Use CCrISP algorithm
** Is tube displaced or blocked?
*** If displaced, pt will be breathing through nose/mouth
**** Generally safer to remove, give oxygen, monitor. Don't reinsert until experienced help arrives.
**** If bag/valve/mask - need to occlude stoma
**** If upper airway patent - oropharyngeal intubation on ward
**** If upper airway not patent - reintubate in theatre - if the tissue is friable you may need to use something softer to guide it in like NGT, if normal tissue use a bougie
*** If partially blocked
**** Cough
**** Suction
**** Oxygen via tracheostomy and facemask
**** Remove/change inner canula
*** Completely blocked
**** CALL FOR HELP
**** Try suctioning - if you can pass the suction, it's not completely blocked
**** Remove inner cannula if present, or if not, saline lavage and suctioning
**** Establish an airway by other means
* Subcutaneous emphysema/PTX
* Bleeding (<48 hours)
** Usually trauma to anterior jugular or inferior thyroid veins
* Early displacement
** Default and safest option - re-intubate the patient orally, then evaluate for replacement. Can safely put a new tube in, preferably via Seldinger.

== '''Late complications''' ==

* Tracheal stenosis and malacia
* Bleeding
** Tracheoarterial fistula
*** See full topic under 'vascular trauma'
*** Sentinel bleeds are common!
**** If you suspect sentinel bleed, do a CT angio (?high-riding innominate artery - ?relationship of wall to artery) and bronchoscopy
*** Survival 14%
*** Erosion into anterior tracheal wall, resulting in fistulous connection with innominate artery
*** Ward:
**** Resuscitation
**** Bleeding from stoma site - apply pressure, silver nitrate
**** Bleeding from deep to stoma - overinflate cuff to compress artery. Can also try inserting ETT and inflating cuff distal to bleed. Otherwise put a finger through the hole then pull anteriorly. And put pressure above sternal notch to compress innominate artery.
*** Operative management:
**** Utley maneuvre - involves dissection to innominate artery
**** Definitive control will probably require sternotomy
* Reduced phonation
* Late displacement
** Check cuff, tube, other components
** Preoxygenate via stoma
** Use obturator to reinsert - stop if resistance



[[Category:Thoracics]]